Most common mental disorders - becoming anxious, distressed or depressed - are dealt with by family doctors. In order to be able to understand the situation in South Manchester, we start by comparing figures for all mental disorders here with the situation in the country as a whole (Table I). The figures in the vertical columns are like Russian dolls: each figure below is contained within the figure above it!

It is a great privilege to be asked to give this memorial lecture. There must be few in this audience who do not know the name of Jack Kahn, if only from his classic writings on school refusal. To many of us, however, he was a dear friend as well as a rather special colleague. I seem always to have known Jack, although in fact I probably first met him in the middle ‘60s at just such a residential conference as we are having now, on that occasion in Harrogate. This was in the days of the RMPA. Jack was chairman of the Child Psychiatry Section and the guiding spirit behind the organisation of that particular conference. I recall particularly the concluding session on the Saturday morning when to our surprise (although we would be less surprised to-day) the presentation was not by one of our members or distinguished guests but by a local dramatic society who presented us with one scene from a play which Jack, as master of ceremonies with his customary skill and flair, used as the catalyst for an exciting large group discussion.

Recently, concern has been expressed by mental health professionals, MIND, and the police regarding the management of Section 136 referrals, which at present varies according to the local psychiatric services available. In the majority of London Metropolitan Boroughs a person deemed to be in need of care and control is taken first to a police station where the necessary documentation is completed and then transported, often a considerable distance, to a mental hospital for the purpose of assessment. This can result in lengthy delays in a police cell for the patient, time-consuming negotiations with hospitals for the police, and problems completing the assessment procedure due to lack of availability of social workers. The importance of considering alternatives, particularly with the move towards community care, has been stressed.

One of the main concepts in the new Children Act (1989) is that of parental responsibility, which will significantly alter the practice of family law and that of mental health professionals dealing with the troubled family. Instead of an assumption that parents have absolute authority over their children, there is the notion of a partnership between parents and children, with the power of the parent decreasing as the child grows in maturity and understanding. There is an emphasis on partnership between parents and those who will have to share in having parental responsibility when it has broken down. Thus the new Act is essentially child centred. It affirms the principle, current in Wardship proceedings, that the child's welfare shall be the court's paramount consideration.

There has been a rapid growth in the number of patients receiving secure and special care in private hospitals, although their overall numbers are still comparatively small. The behavioural modification unit at St Andrews Hospital, Northampton, has the largest concentration of detained patients outside the National Health Service (NHS), but there are plans to increase the number of beds at Kneesworth House, Royston, Herts, and Stockton Hall, Yorkshire. St Andrews Hospital has been run as a charitable trust but Kneesworth House and Stockton Hall are currently owned by a private French company, Generale de Santé division of Generale d'Eau, together with Langton House, Dorset, which provides places for disturbed adolescents. Marks & Thornicroft (1990) noted that recent entrants into the private sector have been from private for profit rather than voluntary non-profit providers, catering for what are seen as “market niches” such as eating disorders, impotence, alcohol or substance abuse, and stress reactions. They criticise these developments, claiming that few people benefit and that the “bull market” in private hospital development challenges the catchment area concept and seems to be producing a two-tier system of psychiatric care in Britain.

Active voluntary euthanasia may be defined as the deliberate taking of a patient's life, or the facilitation of his or her suicide, with the informed consent and at the express request of the patient. It may therefore be distinguished from passive euthanasia, when no positive step is taken to hasten death but when potentially life-saving measures are intentionally withheld, and also from non-voluntary euthanasia, when the patient is unable to participate in the decision, or is incapable of providing an adequately informed consent.

The persecution of civilians by the Iraqi forces in Kuwait and subsequent acts of revenge on the Palestinian population have caused widespread revulsion throughout the world. Stories of torture and rape have been described in the Western media and issues of human rights have gained considerable prominence of late. Perhaps now is a good time to examine how Britain responds to the needs of survivors of torture who seek asylum here.

Of the very large sum of money spent on mental health services, almost all comes from the public directly in the form of central or local government taxation. In 1990, approximately £2 billion was spent in the National Health Service directly on mental health services. That represents 10% of total health service expenditure. In addition, local authority social services departments spend around £50 million annually on residential and day care services for people with mental problems. A further £100 million is spent on supplementary benefit for board and lodgings payments and a considerable amount expended by prisons, courts and the police. These figures omit the growing amount of money spent on supporting elderly people with senile dementia outside mental illness hospitals, in residential and nursing homes. Almost two thirds of all residential care for elderly people provide care for those with mental disorder, adding a further staggering £5–600 million by 1990. The current direct care costs of disabling mental disorder to the public purse is approximately £3,000 million (£3 billion). For all the huge amount of money, resources appear inadequate, ill-directed and uncoordinated. Several actions need to be taken to improve the use of these vast resources.

When the Liverpool Daily Post, its sister paper, the Liverpool Echo, and the Daily Mail published inflammatory material about a restricted patient at Park Lane Special Hospital (now Ashworth (North) Special Hospital) their editors were strongly warned by the House of Lords that they would be well advised to exercise greater care in future, that they did not overstep the mark and find themselves in contempt of court. The newspapers won their appeal because the law allowed them to report the fact that a restricted patient had applied to a Mental Health Review Tribunal for his discharge, the date and place of the hearing of the application and any order made discharging the patient, absolutely or conditionally. But the law does not give the papers carte blanche to comment on a case in order to mount a campaign of public protest against the patient's release.

The closure of Britain's large psychiatric hospitals, long foreseen, is now rapidly becoming a reality. Surprisingly little is known about the process and outcome of the relocation of long-stay hospital residents. One area of particular concern is the fate of ‘elderly graduate’ patients, who are by convention defined as long-stay patients aged over 65 years who came into continuous psychiatric contact before the age of 65. (More cynically they might be defined as those elderly patients whom our colleagues specialising in the psychiatry of the elderly choose not to take over). This paper documents the experience of a specialist resettlement team working within a declining mental hospital attempting to place ‘elderly graduate’ hospital residents into community provision.

In 1975 Sims published his celebrated paper on ‘Factors Predictive of Outcome in Neurosis’ (Sims, 1975). A big chart was associated with a poor prognosis.

In the past decade there has been a rapid diversification of services provided for patients with chronic psychiatric illnesses. Although these services are thought to be beneficial for those who use them, there has been little in the way of objective evaluation. As new services begin to compete for the limited resources available, it has been recommended that they should demonstrate their effectiveness. This paper reports a small pilot study on the value of an arts based service known as START (Bridges & Brown, 1989) which won a BBC ‘It's My City’ competition in 1989. It has been a popular component of the rehabilitation services of the Department of Psychiatry, Manchester Royal Infirmary since its inception in 1986.

Recommendations in the White Paper Working for Patients will have a major influence in the field of child health. District consultants have been asked by colleagues and managers to explain and account for current practice in child and adolescent psychiatry, and to plan for the future against a background of serious financial constraint. Similarly, child and adolescent psychiatrists will need to evaluate current levels of use of regional services and consider a relationship where these services may have to be bought from a limited child and adolescent psychiatry budget.

Depression is a very common disorder. It has been estimated that 20% of all women and 13% of all men will develop depression at some time during their lifetime, although much of the depression which exists in the community is unrecognised and untreated. Approximately 75% of the female population and over 50% of the male population attend their general practitioners at least once with a psychiatric complaint, of whom 70% of the women and 34% of the men have a depressive episode. While treatment for some patients will be successful following the acute phase of the depressive episode, it will generally take at least three months and in some instances six months or more to treat an episode. The risk of relapse following treatment is high, affecting approximately 50% of patients treated; furthermore, there is no evidence to suggest that those patients being treated for their first episode of depression are less vulnerable to relapse following response to treatment than those who have suffered previous episodes of depression.

Community orientated mental health services are rapidly developing in Britain today, and as part of this development many community mental health teams (CMHTs) are being established. This study looks at some of the relationships between members of one CMHT and local primary health care team members and social workers, with particular emphasis on communication between these various professionals.

It seems that increasingly patients are being referred to primary care teams and GPs in health centres rather than to psychiatrists in a hospital setting. With the growth in the number of patients being maintained in the community, it is becoming more important to pay attention to this sphere and to aid primary care teams to be clinically effective. It was from this perspective that I became involved as facilitator to a primary care team on a one year project.

The sudden collapse of the communist order in Czechoslovakia and the formal installation of the new government in June 1990 has led, inter alia, to a fundamental reappraisal of mental health care. On a visit to Prague in September 1990 the system under the 40-year-old communist regime was still largely intact but clearly about to undergo major changes. Among the reform proposals made by a working group of the Ministry of Health and Social Affairs of the Czech republic are practices familiar to western psychiatrists: mental health care and specialist liaison in primary care settings; formal specialisation within psychiatry into general adult psychiatry, psychogeriatrics, child and adolescent psychiatry, psychotherapy; psychiatric units in general hospitals; community care with restructuring of funding away from the mental hospital budget and devolution to districts. More “humanisation” of psychiatry is envisaged, with choice of consultant, increased competition between doctors and legal definitions of involuntary treatment (Potucek et al, 1990). Voluntary organisations, existing until recently only underground, will be encouraged as also will be counselling services. Dementia, and drugs and alcohol misuse, are seen more as social service than medical issues. Of particular interest is a proposal to separate mental health funding from the rest of the health care budget.